1. A Physician’s Perspective Lisa A. Laurent, MD Advanced Radiology Consultants Park Ridge, Illinois
Fellow Institute of Medicine of Chicago
Medical Director Body CT
Medical Director Ultrasound
Advocate Lutheran General Hospital
Park Ridge, Illinois
Unless otherwise indicated, all trademarks are owned by MEDRAD, INC. or licensed for its use.

2. Current Situation Advocate Lutheran General Hospital
638 bed hospital
5 CT suites
22 technologists (all registry certified)
Upgraded 16 GE slice to 64-slice GE Discovery™ CT750 HD
Commenced implementation of Adaptive Statistical Iterative Reconstruction (ASIR)
Located in busy Level I ED trauma center

3. Implementation Issues
Creation of contrast protocols for the new scanner with ASIR technology
How do you create protocols as you change radiation dose?
How do you increase image quality?
What are tools to ensure continuous improvement?
Partners in development
Contrast company
OEM scanner
Injector company
Identified PE studies as a potential challenge

4. CT Pulmonary Angiography (PA) Challenges
Gold standard for diagnosis of pulmonary embolism
High percentage of sub-optimal diagnostic studies
University of Pittsburgh Medical Center %*
University of Albany %†
Kelly AM, Patel S, Kazerooni EA. CT pulmonary 24% angiography for accurate pulmonary embolism in ICU patients clinical experience (abstr.) Radiology ; 225(p):385
Sub-optimal studies have been shown to result in additional*
Imaging studies
Medical therapy
Hospital admission
CTPA is gold standard for ruling out PE
CTPA has been shown to have a high percentage of sub-optimal studies
And sub-optimal studies have repeat exams or other exams ordered. Sometimes with admission & therapy given because they just can’t tell.
*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1. Society of Thoracic Radiology E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.
†Patient Outcomes and Resource Utilization for Emergency Department Patients with Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed Suboptimal for Interpretation; Annals of Emergency Medicine; VOLUME 54 NUMBER SEPTEMBER 2009; Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY

5. P3T® PA Clinical Trial*
“Higher percentage of exams ranked as diagnostic without limitation…”
“Better contrast enhancement of pulmonary arteries…”
Note: at a slightly higher contrast dose than standard scan protocol at 80 mL
Implementing P3T to rule out PE in a clinical trial at UPMC (GE64, 350 concentration, 60pt)
P3T demonstrated higher percent of diagnostic studies
Going back to what happens with sub-optimals… this is potentially reducing radiation exposure to patients due to possibly lower repeat rate
Better contrast enhancement
It did have a slightly higher dose vs the standard protocol
*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1.  Society of Thoracic Radiology E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.

6. P3T® PA Results: Pulmonary CTA
Qualitative Assessment of CTs Obtained With P3T® vs Standard Protocol*
(Lacomis, Deible, Federle) University of Pittsburgh
Presented at Society Thoracic Radiology 2008, Submitted to AJR in 2010
60 patient (prospective and randomized design) study, ED patients suspected of PE
64-slice VCT (GEHC)
Omnipaque 350 mg/ml
August 2006 to March 2007
*Used by permission.

7. Advocate Lutheran General
Hospital Experience

8. Implementation Plan Invest in Certegra™ software package from MEDRAD
P3T® PA – weight-based dosing software for PA
Connect.PACS™ Application
Manage.Report™ Application
Significant training plan

9. P3T® Software
P3T® calculates the appropriate dose for each patient by computing custom injection protocols, enabling personalized care and patient care while maintaining efficient workflow

10. P3T® Software
P3T® calculates custom injection protocols as well as scan timing for each patient using 4 primary components
Patient and procedure data gathered by health care personnel
P3T® algorithm for protocol generation
DualFlow technology (the simultaneous injection of contrast and saline)
Use of a transit or timing bolus

11. PE Exam Challenge and Process
The challenge: to perform diagnostic quality PE exams in a consistent fashion for all patient body habitus types, regardless of age and clinical presentation
The process: to implement P3T® Software
Retrospectively reviewed all adult PE studies performed since May 1, 2011
Used software tracking processes
Determined best practices for coaching technologists, educating radiologists, and developing a team approach to create total departmental engagement

12. How Is This Analysis Made Possible?
Data
Accurate
Accessible
Automated
Connect.PACS™ Application
Point-of-care decision
Provides a way to retrospectively analyze data
Real-world proof as opposed to assumption

13. Using the Data to Drive Results
Easily able to identify reasons behind PE limitations
Technologist adoption
Flow-rate—limiting issues
Contrast efficiency

14. Using the Data to Drive Results
Building a Team

15. Protocol Adherence: First 6 Weeks

16. Protocol Adherence: Last 6 Weeks

17. PE Exam Analysis Breakdown
199 PE exams completed (May 1, 2011, through July 31, 2011)
23 exams deemed nondiagnostic (11.6%)
14 of these exams, the technologist did not use P3T® (7.0%)
9 nondiagnostic exams used P3T® (4.5%)
3 caused by motion artifact
1 caused by the use of Isovue® 300 vs Isovue 370
5 caused by flow-rate-limiting issues due to catheter restrictions

18. CT Chest Pulmonary Embolism Suboptimal Analysis
199 Total Studies
May 1st – July 31st
110 with P3T
89 without P3T
55%
45%
9 Sub-Optimal
14 Sub-Optimal 8%
16%
23 Total Suboptimal Studies

19. PE Exam Analysis Breakdown
219 exams reviewed (August 1, 2011 through October 19, 2011)
17 exams deemed suboptimal (7.8%)
All exams used P3T® software
Cross referenced Certegra™ data vs RIS
Data-mining capabilities identified that 8 of the 17 exams were performed during a certain time of the day
Facilitated focused education and coaching to improve results in the future

20. PE Exam Analysis Breakdown
ALGH results and progress since May 1st Certegra™ implementation
Non-diagnostic/Suboptimal PE Exams

21. Snapshot of Data Gender Study Time Study Description Brand
Concentration
Lot
Loaded (mL)
Delivered (mL)
Female
2:54
CT CHEST PULM EMBOLISM
Isovue
370 --
96.51
95.43
1:24
92.5
73.61
Male
21:00
95.44
11:12
74.45
49.59
5:00
100.61
73.35
0:33
92.54
91.68
11:53
74.55
73.14
18:14
96.59
95.24
1:12
120.78
119.45
17:04
90.78
23:34
68.55
67.15

22. ACR Guidelines for Communication of Diagnostic Findings
Procedures and materials
The report should include a description of the studies and/or procedures performed and any contrast media and/or radio-pharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere.

23. Documentation Gaps Analysis of Documentation Accuracy Methodology
RIS (Manual Capture)
PACS (Manual Capture)
Injector (Automated)
Methodology
Pulled 102 accounts and reviewed documentation across 3 different documentation techniques

24. Examples

25. Results of Documentation
Deviation from Actual Injection Record

26. Other Observations on Manual Data
No Saline Delivery Information Captured
No Flow Rate Information Captured
Protocol Information Not Captured

27. Vision – Offer Closed Loop Contrast Dose Management
history
Hospital
Ref Physician
HL/7
Radiology
HL/7
ISI
Protocol
Management
HIS/EMR
PHR
CT scanner
DICOM
Stellant
RIS
Pharmacy
Billing
Reporting
DICOM
Certegra
Speech
Recognition
PACS
Modality
Utilization and Analytics
MEDRAD Confidential, Internal Use Only

28. Appendix

29. Flow Rates and Pressures
Pressure Related to Contrast Flow Rates with 22 g Catheters for CT Exams
Flow rates with Isovue® 300 concentration (mL/s)
Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

30. Flow Rates and Pressures
Pressure Related to Contrast Flow Rates with 20 g Catheters for CT Exams
Flow rates with Isovue® 370 concentration (mL/s)
Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

31. Using the Data to Drive Results
Contrast Efficiency

32. Contrast Efficiency
For the past 219 PE exams: ALGH averaged 79.3 mL of contrast Compared to 100 to 125 mL of contrast without P3T® software

33. Contrast Waste Per Month

34. Conclusions
Delivering contrast has become more challenging with the faster scanners
CT suites need more tools to customize the dose per patient and manage results
Using P3T® PA for PE exams, ALGH improved diagnostic outcomes while lowering contrast volumes
Connect.PACS™ tools allowed for accurate quality analysis of PE exams and established action plans for further improvement

35. THANK YOU
Questions? 35